Robert Fulford: Feeding the illness industry machine thanks to DSM5

Feeding the illness industry machine thanks to DSM5

Once again the armies of psychiatry are on the move, marching like imperial legions into unconquered territories of the human spirit. Psychiatrists do excellent work as individuals but when they join international bureaucracies they can cause trouble and look foolish.

The evidence is the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders, known as DSM-5. It’s now in final draft, scheduled for release during the American Psychiatric Association annual meeting next May.

Authors of the various DSM editions appear anxious to demonstrate that just about every trace of emotional discomfort deserves professional attention. Sadness is being reclassified as sickness. The medicalization of everyday life is progressing with astonishing speed.

People not directly involved may view this with a light heart, as fresh intellectual confusion created by pretentious, over-confident experts. It’s more serious for patients. A medical label that’s invented by an ambitious theorist and carelessly applied by an untrained doctor can erode self-confidence. A diagnosis takes on a life of its own.

Habitually, the DSM volumes lead to over-diagnosing and over-prescribing. Grief, for instance, receives special DSM attention. Humanity traditionally regards sorrow as a part of life but in the DSM it indicates depression. In DSM-5, reactions to grief lasting longer than two weeks may be diagnosed as depression, perhaps requiring antidepressants.

Kenneth S. Kendler, a Virginia psychiatrist who serves on the DSM mood disorder committee, has answered criticism of the grief proposal — but answered it in a way that suggests he doesn’t understand the impact of what he’s doing. He says we needn’t worry that grieving individuals will be automatically treated as depressives. In psychiatry, watchful waiting is an important tool, and a psychiatrist with a patient who appears depressed after a bereavement will start with a careful diagnostic evaluation.

But DSM-5 will be used by many family doctors who have no time for watchful waiting and no training for a diagnostic evaluation. It’s been credibly estimated that in the U.S. about 80% of drugs for mood disorders are prescribed by non-psychiatrists, usually GPs.

In the current round of controversy, critics of DSM-5 have a surprising champion — Allen J. Frances, former head of psychiatry at Duke University.

He chaired DSM-4, the current edition, published in 1994. He admits it got out of control. Unjustified expansion of illness categories happened on his watch and he’s campaigning by speeches and blogs to get it right this time.

The case of Attention Deficit Hyperactivity Disorder (ADHD) is one of his concerns. Earlier versions of the DSM have encouraged excessive diagnosis, creating the appearance of an international epidemic of ADHD.

And now, Frances says, DSM-5 is about to lower the threshold for diagnosis, which means there will be still more kids given Ritalin and more articles about ungovernable, badly reared children.

A University of British Columbia study, released earlier this year, shows how this works. Over 11 years, researchers surveyed the records of 937,943 children, searching for factors that lead to the ADHD diagnosis. They discovered that the youngest children in any classroom are the likeliest to be identified as suffering from ADHD.

Given the schedules of Canadian schools, children born in December are roughly a year younger than their oldest classmates. They likely suffer from greater frustration and anxiety, producing ADHD-like symptoms. Those born in December, compared to those born in January, are 39% more likely to be classified ADHD and 48% more likely to receive ADHD medication. Clearly, many children being medicated for ADHD are in truth being medicated for their age.

Why is the DSM so anxious to uncover new categories of mental illness and inflate the more familiar categories? Drug companies hope to develop new drugs and expand the market for old ones but lobbying by psychiatrists with specialized interests carries more weight. As Allen Frances says, “Experts always overvalue their pet area and want to expand its purview.”

Some disorders even have their own lobbies. This month Eating Disorder Hope, an on-line publication, celebrated the news that DSM-5 will elevate the status of binge-eating disorder (BED), shifting it from the appendix (where rookie disorders nervously await acceptance as proper illnesses) to a distinct category of eating disorder. Patients who binge once a week for three months will be officially BED. Eating Disorder Hope says this means their treatments will be covered by their insurance.

Frances considers that section another DSM mistake. But, like everything else in this vast catalogue of sorrows, it satisfies at least one corner of the steadily increasing illness industry.

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